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Claims Rework Reduction

Claims Rework Reduction. Lean Six Sigma Black Belt Project Final Report 06 Jun 08. Black Belt Candidates : Andy Booth Mary Kay Gilbert. From the charter:.

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Claims Rework Reduction

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  1. Claims Rework Reduction Lean Six Sigma Black Belt Project Final Report 06 Jun 08 Black Belt Candidates: Andy Booth Mary Kay Gilbert

  2. From the charter: Project Description: To reduce claims rework rate by indentifying and addressing the root causes which motivate members/providers to contact us. In addition, to streamline the current Claims & Claim Inquiry process as well as ensure that the Perfect Service characteristics are incorporated into the process. Problem Statement: CompBenefits Dental processed claims produce a significant number of phone calls (300+K) and claims inquiries (1.9%) that dramatically increase the cost of processing claims.

  3. CompBenefits Org chart

  4. SIPOC

  5. DENTAL CLAIMS PROCESS MAP- AS IS - 45% received electronically - 45% received via paper and sent to data entry outsourcer - 10% received/processed via paper Claims Presort Dental Claims 2.1 Million - 63% claims auto adjudicated decision - 37% claims manual decision Claims Processed Claims Processing - 35% claims go to HCI for code edit review - 4% of claims go to P&R for professional review Claims Review Claims sent to outsourced companies for review Claims sent from Outsourcers back to CB Claims Determination • 87% of claims approved • 13% of claims declined Claims System Claims Approved/Declined

  6. DENTAL CLAIMS INQUIRY PROCESS MAP – AS IS Dental Claims Processed 2.1 Million Claims Process 87% Claims Approved 13% Claims Declined Customer Contacts Company regarding claims status 300k calls/ 5k e-mails • 87% questions resolved over phone/ e-mail • 13% requires claims inquiry Customer Customer Care opens Claim Inquiries for unresolved issues 38k Claims Inquiries Customer Care • 89% of claims inquiries resolved by reprocessing • claims (61%) or returned to customer care (28%) • 11% of claim inquiries require re-contact by customer Claims Resolves Inquiries Claims

  7. Cost-volume

  8. Voice of the Customer

  9. Historical Claims & Error Data

  10. Average: 2.45 days

  11. Standardization & Variation

  12. House of Quality

  13. Improvements • Kaizen Event • Eliminate P&R outsourcing • Standardize training for Customer Care Reason Codes • Reduce # of codes from 43 to 12 • Coerce/reward providers into automated/online submittal

  14. DENTAL CLAIMS PROCESS MAP- Redesigned - 65% received electronically (from 45%) - 35% received via paper and sent to data entry outsourcer (now single vendor) - 0%processed paper only! Claims Presort Dental Claims 200K - 76% claims auto adjudicated decision (from 63%) - 24% claims manual decision (from 37%) Claims Processed Claims Processing - 23% claims go to HCI for code edit review (from 35%) Claims Review Claims sent to outsourced company for review Claims sent from Outsourcer back to CB Claims Determination • 93% of claims approved (from 87%) • 7 % of claims declined (from 13%) Claims System Claims Approved/Declined

  15. Questions ?

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